Intracardiac cell delivery and cell transplantation

ABSTRACT

A method for delivering a cell to a heart of a patient comprises the steps of providing an apparatus for intracardiac drug administration comprising a catheter wherein the catheter has at least one position sensor which generates signals responsive to the position of a catheter and a drug delivery device for delivering the cell. The catheter is inserted into a chamber of the heart at a site and the cell is delivered to the site with the drug delivery device in response to the signals from the position sensor. Typical cells useful for delivery are either myoblasts or myocytes. These cells may be utilized as either an expression vector for promoting angiogenesis or for cell transplantation and fusion through myogenesis.

This is a continuation in part of U.S. patent application Ser. No.09/019,453 filed Feb. 5, 1998 now U.S. Pat. No. 6,309,370.

FIELD OF THE INVENTION

The present invention relates generally to methods and devices forinvasive cardiac treatment, and specifically to methods and devices forminimally invasive treatment of cardiac ischemia.

BACKGROUND OF THE INVENTION

Heart disease or heart failure is still the major cause of death in theWestern world. One of the most common forms of heart disease is theformation of ischemic regions within the myocardium resulting from poorblood perfusion, either due to chronic coronary arterial disease orfollowing acute myocardial infarction. Cells within ischemic zonesundergo a gradual, generally irreversible, degeneration processeventually rendering them dead (see M. C. Fishbein, M. B. McLean et al.,Experimental myocardial infarction in the rat, Am. J. Pathol. 90: 57-70,1978). This process is expressed as a corresponding progressivedeterioration of the viability of the ischemic zone.

Currently available approaches for treating coronary arterial diseasesymptoms include methods of restoring blood flow to a large localizedsegment of the epicardial coronary arterial tree (angioplasty) andbypassing the obstruction within the coronary arteries entirely, byperforming a bypass graft.

Drug administration, for example, administration of cytoprotectivecompounds which prolong anaerobic cell viability, and laser myocardialrevascularization, which improves blood supply to an affected myocardialregion, are further therapeutic approaches (some still under testing)for treating ischemia.

It has been observed in some cases of myocardial ischemia that new,collateral blood vessels may grow in the heart to augment the supply ofoxygen to the ischemic tissue. This phenomenon is known as angiogenesis.Recent advances in the understanding of mechanisms governing suchangiogenesis, based on naturally-occurring substances known as growthfactors, such as vascular endothelial growth factor (VEGF) andfibroblast growth factors (FGF), have added a novel possible form oftherapy based on administration of exogenous angiogenic growth factorsto the heart.

Several mechanisms have been proposed to explain the observed beneficialeffect of growth factors on alleviating chronic and/or acute ischemia.These mechanisms include angiogenesis, increase in myocyte viability andresistance to injury, restoration of ischemia-impairedendothelium-dependent vasomotion, and recruitment of preexistingcollateral vessels (see, J. A. Ware and M. Simons, Angiogenesis inischemic heart disease, Nature Medicine, 3(2):158-164, 1997, which isincorporated herein by reference).

Harada et al. (Basic fibroblast growth factor improves myocardialfunction in chronically ischemic porcine hearts, J. Clin. Invest.,94:623-630, 1994, which is incorporated herein by reference) report thatperiadventitial administration of basic fibroblast growth factor (bFGF)to pigs with gradual (artificially induced) coronary occlusion resultedin improvement of coronary flow and reduction in infarct size, as wellas in prevention of pacing-induced hemodynamic deterioration. The growthfactor was administered extraluminally to both occluded and neighboringarteries by applying a number of capsules holding beads containing bFGFand securing them to the artery. The beads were designed to slow-releasetheir bFGF content at a predictable rate over a prolonged period oftime, in order that the bFGF be effectively absorbed and transported toaffected myocardial zones.

By comparison, intravenous administration of bFGF, including continuoussystemic infusion, as opposed to periadventitial administration, wasreported to exhibit only a minor angiogenic effect, mainly due towashout of the drug by the blood stream resulting in dilution, and a lowretention time. (See E. R. Edelman et al., Perivascular and intravenousadministration of basic fibroblast growth factor: Vascular and solidorgan deposition, Proc. Natl. Acad. Sci. USA, 90:1513-1517, 1993; G. F.Whalen et al., The fate of intravenously administered bFGF and theeffect of heparin, Growth Factors, 1:157-164, 1989; and E. F. Unger etal., A model to assess interventions to improve collateral blood flow:continuous administration of agents into the left coronary artery indogs, Cardiovasc. Res., 27:785-791, 1993, which are incorporated hereinby reference).

In a later paper (K. Harada et al., Vascular endothelial growth factoradministration in chronic myocardial ischemia, Am. J. Physiol. 270[Heart Circ. Physiol. 39]: H1791-H1802, 1996, which is incorporatedherein by reference), the authors report similar beneficial angiogeniceffects of vascular endothelial growth factor (VEGF) in pigs. The VEGFwas administered by a microcatheter placed adjacent to an ameroidconstrictor (i.e., an external ring of appropriate internal diameter,which is placed around the artery in order to induce a gradual occlusionthereof) and secured directly to the heart musculature distal to theconstrictor. The microcatheter was connected to an osmotic pump (ALZET,from Alza, Palo Alto, Calif.) placed inside the chest wall, outside thepericardial cavity.

An alternative approach for stimulating angiogenesis is gene therapy.Simons and Ware (Food for starving heart, Nature Medicine, 2(5):519-520,1996, incorporated herein by reference) report still another growthfactor, FGF-5, as having the capability of inducing myocardialangiogenesis in vivo when administered using a gene transfer deliveryapproach employing adenoviral vectors as transfer agents. Similarly, J.M. Isner (Angiogenesis for revascularization of ischaemic tissues,European Heart Journal, 18:1-2, 1997, incorporated herein by reference)reports treatment of critical limb ischemia by intra-arterialadministration of “naked DNA” including the gene encoding vascularendothelial growth factor (phVEGF). The solution of plasmid DNA isapplied to the hydrogel coating of an angioplasty balloon, which retainsthe DNA until the balloon is inflated at the site of gene transfer,whereupon the DNA is transferred to the arterial wall.

Accumulated results seem to indicate that the drug delivery approach ofchoice for growth factors ought to be a local, rather than a systemic(intravenous), delivery approach. The preferability of local deliverymay stem from the low half-life of injected bFGF and its short retentiontime. Prolonged systemic intravenous delivery of bFGF has been reportedto result in the development of significant hematological toxicity,which did not completely resolve even 4 weeks after treatment, as wellas hypotensive effects. In addition, dilution effects associated withwashout of the drug by the blood stream render the drug quantitiesrequired for such an approach prohibitively high. (See J. J. Lopez etal., Local perivascular administration of basic fibroblast growthfactor: drug delivery and toxicological evaluation, Drug Metabolism andDisposition, 24(8):922-924, 1996; and J. J. Lopez and M. Simons, Localextravascular growth factor delivery in myocardial ischemia, DrugDelivery, 3:143-147, 1996, which are incorporated herein by reference.)

Local sustained delivery, on the other hand, is free of at least some ofthe above-mentioned drawbacks and is apparently more effective. The maindrawback of the local delivery approach employing present availabletechniques, as cited above, is its extensively invasive nature. Themethods described in the articles cited above involve open chestsurgery. Despite apparent physiological and therapeutic advantages,there is no currently available technique for effective,locally-targeted, minimally invasive technique for intracardiac drugdelivery, particularly a technique based on controlled-releaseadministration.

U.S. Pat. Nos. 4,578,061, 4,588,395, 4,668,226, 4,871,356, 5,385,148 and5,588,432, which are all incorporated herein by reference, describecatheters for fluid and solid-capsule drug delivery to internal organsof a patient, generally for use in conjunction with an endoscope. Thecatheters typically comprise a needle or a tube disposed at a distal endthereof, communicating with a fluid or solid dispenser via a duct. Noneof the disclosed catheters, however, comprise means for accurateposition-controlled delivery of therapeutic drugs.

SUMMARY OF THE INVENTION

It is an object of some aspects of the present invention to provideaccurate minimally-invasive methods and apparatus for intracardiacadministration of drugs to the myocardium.

In some aspects of the present invention, such methods and apparatus areused for accurate placement of controlled-release drug delivery devices.

In the context of the present patent application and in the claims, theterm “controlled-release” is taken to refer to any and all techniques ofsustained, controlled delivery of liquid or soluble compounds, includingall forms of polymer-based slow-release and local continuous infusion.

Some aspects of the present invention are based on the finding describedabove that angiogenic growth factors, when properly administered tocardiac ischemic zones exhibiting marginal viability, induce and/orpromote angiogenesis therein, thus augmenting blood perfusion.Preferably, the growth factors are administered at a known,predetermined depth within the heart tissue.

Accordingly, in preferred embodiments of the present invention,minimally-invasive intracardiac drug delivery (MI2D2) apparatuscomprises a catheter having a distal end for insertion into a chamber ofthe heart. The catheter is used to administer a drug at one or morepredetermined locations within the myocardium. The catheter comprises aposition sensor, which is used to navigate and position the catheteradjacent to each of the one or more locations, and a drug deliverydevice, coupled to the dispenser, for administering a drug at thelocations. The drug delivery device is disposed at or adjacent to thedistal end of the catheter and injects or otherwise delivers the druginto the myocardium to an appropriate depth.

In some preferred embodiments of the present invention, the catheteralso includes one or more physiological sensors, for diagnosis andidentification of sites in the myocardium that are in need of drugadministration. Preferably, the sensors are used to identify ischemicareas in which growth factors are to be administered. Most preferably,the physiological sensors are used in conjunction with the positionsensor to produce a viability map of the heart, in accordance with whichthe drug is administered, as described further hereinbelow.

In some preferred embodiments of the present invention, the catheter isoperated in conjunction with a drug dispenser, which meters anddispenses predetermined quantities of the drug, and a control circuit,for controlling and triggering the operation of the apparatus. The drugdelivery device in the catheter preferably communicates with thedispenser via a suitable duct, i.e., a lumen or a tube extending alongthe length of the catheter. In preferred embodiments of the presentinvention, the catheter and associated drug delivery apparatus are usedto administer growth factors to the myocardium, but it will beappreciated that the apparatus may similarly be used to accuratelyadminister therapeutic agents of other types, as well.

Preferably, the position sensor comprises a magnetic position sensor, asdescribed in PCT Patent publication number WO96/05768, which isincorporated herein by reference. Further preferably, the catheterincludes a steering mechanism, for example, as described in U.S.Provisional Patent Application 60/042,872, which is assigned to theassignee of the present patent application and incorporated herein byreference. Alternatively, the steering mechanism may be of any suitabletype known in the art, such as are described in PCT Patent ApplicationPCT/US95/01103 or in any of U.S. Pat. Nos. 5,404,297, 5,368,592,5,431,168, 5,383,923, 5,368,564, 4,921,482 and 5,195,968, all of whichare incorporated herein by reference.

As mentioned above, accurate location of the drug administrationsite—relative to the borders of the ischemic region and the depth withinthe heart wall—is important in the successful completion of thetreatment, and presence of excessive amounts of the growth factor inhealthy tissue may have adverse effects thereon. Administration of thegrowth factor over an area that exceeds the borders of the ischemicregion, or near the surface of the endocardial wall, where it may bewashed away by the blood, compromises the therapeutic effectiveness ofthe treatment, poses toxic risks and adversely increases the drugamounts needed for achieving the desired therapeutic effects. Therefore,it is important to accurately navigate, locate and orient the catheterwith respect to the ischemic regions designated for drug administrationand to assure proper contact between the engaging surface of thecatheter and the heart wall.

Accurate location and orientation of the catheter is accomplished usingthe position sensor and steering mechanism mentioned above. Furthermore,in some preferred embodiments of the present invention, the cathetercomprises one or more proximity or contact sensors, for sensing andassuring contact between the catheter and the heart wall. In some ofthese preferred embodiments, the catheter comprises at least threecontact sensors disposed on the surface of the catheter's distal end soas to assure proper contact between the catheter and the heart wall andultimately, penetration of the injected drug to a desired depth.

In some preferred embodiments of the present invention, the catheter isnavigated and located with respect to a viability map, which identifiesareas of the heart muscle that are ischemic but still viable, as againstadequately perfused areas on the one hand and infarcted, non-viableareas on the other. Such a map may be produced, for example, usingmethods described in U.S. Pat. No. 5,568,809 or in PCT PatentApplication PCT/IL97/00010, which are incorporated herein by reference,wherein a geometrical map of the heart is generated indicating localviability levels. Preferably, ischemic areas to be treated are marked onthe map with a grid of points at which the drug is to be injected by thecatheter. Preferably, the map and grid are determined based onphysiological activity of the heart indicative of local tissueviability, gathered in conjunction with location coordinates.

In some preferred embodiments of the present invention, viabilitymapping is carried out in conjunction with administration of the drug,using the same catheter. In these embodiments, the catheter comprises asensor for determining viability or non-viability of the myocardialtissue. Such sensors may comprise one or more electro- ormechano-physiological detectors, which sense local myocardial electricalor mechanical activity, respectively, as described in theabove-mentioned '809 patent and '010 PCT application. Alternatively oradditionally, the sensor may comprise an optical sensor, preferablycoupled to a suitable light source and fiberoptic light guides withinthe catheter, which detects autofluorescence of NADH in the myocardialtissue as an indication of the viability, as is known in the art.

Alternatively, the viability map may be generated in advance of drugadministration, using one of the methods mentioned above, and fed to thecontrol circuitry of the MI2D2 apparatus.

In some preferred embodiments of the present invention, the drugdelivery device includes a hollow needle, preferably retractable, asdescribed, for example, in U.S. Pat. Nos. 4,578,061, 4,668,226 and5,588,432, mentioned above. The needle is retracted during insertion ofthe catheter into the heart and removal therefrom, but extends out ofthe distal end of the catheter to deliver the drug inside the heart.Preferably, the needle extends out through an opening which is sealed,using any suitable seal, such as a silicon septum, as is known in theart, so as to prevent a back-flow of blood into the catheter, whileenabling the needle to be projected and retracted a multiple number oftimes. Optionally, the needle itself may be sealed to prevent bloodcomponents from entering thereinto, using a valve, for example, asdescribed in U.S. Pat. No. 4,871,356, mentioned above.

Preferably, the drug delivery device comprises a retraction mechanismcoupled to the needle, which projects and retracts the needle into andout of the catheter, prior to and after drug delivery, respectively, andis capable of multiple projection/retraction cycles. Accordingly, theretraction mechanism may comprise a piston with a constrained strokelength, or another suitable device, as is known in the art. Preferably,a sensor is coupled to the retraction mechanism or to the needle itself,so as to sense when the needle has been fully projected out of thecatheter and into the heart wall, prior to drug administration. Mostpreferably, the sensor also senses when the needle has been fullyretracted into the catheter, to ensure that the catheter can be movedsafely from one location to another. Preferably, drug administration isautomatically disabled except when the catheter is in appropriatecontact with a heart wall and the needle is projected to a desiredlength. Alternatively or additionally, a user of the apparatus isnotified of the needle's position, with or without automaticdisablement.

Further preferably, the drug delivery device or the dispenser comprisesan occlusion detector, for example, a pressure sensor, ultrasonictransducer or flow-meter, as are known in the art, which senses theoccurrence of any occlusion of the needle or flow obstruction along theduct. Such occlusion detection prevents pressure buildup, which maycause ruptures along the flow path of the drug, and assures reliableadministration of the drug at the designated locations.

Typically, ischemic regions in the myocardium extend across areas of upto 10 cm², whereas the typical area of influence of a local growthfactor injection is only a few mm². Employing a single needle for theadministration of the growth factor to the whole affected region rendersthe procedure tedious and time-consuming. Accordingly, in alternativepreferred embodiments of the present invention, the drug delivery devicecomprises a plurality of needles appropriately spaced from one another,connected to a drug feed manifold fed by the duct and capable ofcollective or independent projection-retraction motion.

In some preferred embodiments of the present invention, theadministration of the drug by the catheter is gated in response to theheart rhythm. Preferably, the drug delivery device is controlledresponsive to the thickness of the heart wall, which varies cyclicallyresponsive to the heart rhythm. Thus, if the drug is delivered atend-diastole, for example, when the heart wall is generally thinnest,the drug will generally be dispersed most deeply into the myocardium.

In one such preferred embodiment, the catheter comprises an ultrasoundsensor adjacent its distal end, which is used to measure the localthickness of the heart wall, as described, for example, in theabove-mentioned PCT application PCT/US95/01103. The thicknessmeasurement is used to gate the release of the drug, so that the drug isadministered at an optimal depth within the myocardium, preferably 2-3mm, as described above. Preferably, the heart wall thickness at a drugadministration site is measured at several points in the cardiac cycle,and the thickness measurements are used in determining at what point inthe cycle to administer the drug and in controlling the drug deliverydevice to release the drug accordingly.

Although preferred embodiments of the present invention are describedherein mainly with reference to drug administration, it will beappreciated that these methods of gating to heart wall thickness mayalso be applied to other types of cardiac therapies. For example,thickness-gating may be used advantageously in ablating cardiac tissuefor treatment of arrhythmias or in laser myocardial revascularization(LMR). Methods and apparatus for LMR are described, for example, in PCTPatent Application PCT/IL97/00011, whose disclosure is incorporatedherein by reference. In some of these methods, known commonly aspercutaneous myocardial revascularization (PMR), a catheter is insertedinto the heart, and a laser beam is conveyed by a waveguide in thecatheter to create channels through the endocardium into the myocardium.In others of these methods, known as transmyocardial revascularization(TMR), a probe is inserted through the chest wall and used to createchannels that penetrate into a chamber of the heart through theepicardium and the myocardium.

Thus, in some preferred embodiments of the present invention, a laserused in LMR is gated responsive to the heart wall thickness. Preferably,when LMR is performed using the PMR method, the laser is gated to fireduring systole, when the heart wall is generally thickest, so as tominimize the risk that the laser channel will penetrate all the waythrough the heart wall and out through the epicardium. On the otherhand, when the TMR method is used, the laser may be gated to fire duringdiastole, so as to penetrate through the heart wall with a minimum ofexpended laser energy.

In some preferred embodiments of the present invention, LMR is used inconjunction with growth factor administration to enhance angiogeniceffects. In these embodiments, an integrated catheter comprises awaveguide coupled to a LMR laser source and to suitable optics at thecatheter's distal end, along with the elements for intracardiac drugdelivery described above. The laser is operated to produce LMR channelsin the myocardium, and a dose of the growth factor is then inserted intosome or all of the channels. The use of the growth factor in conjunctionwith LMR is believed to further facilitate angiogenesis within cardiacischemic regions (see, for example, J. A. Ware and M. Simons, citedabove).

In these preferred embodiments, the growth factor drug is preferablycontained in a slow-release capsule, made of an appropriate solid drugdelivery medium, as described, for example, in U.S. Pat. Nos. 4,588,395or 4,578,061, mentioned above. The capsule is inserted into the LMRchannel or may, alternatively, be forced into the myocardium without theuse of LMR. Preferably, the capsule is designed so that its dimensionsremain substantially constant throughout the treatment period, so as tosecure the capsule in place at the designated location and precludeaccidental drift, thus assuring appropriate localized administration ofthe drug throughout the treatment duration.

In other preferred embodiments of the present invention, the growthfactor or other drug is administered in conjunction with irradiation ofthe heart tissue with other types of radiation, for example, RF orultrasound irradiation.

In some preferred embodiments of the present invention, in which thegrowth factors or other drugs are injected into the myocardium in aliquid form or as slow-release microcapsules dispersed in a liquidcarrier, the drug dispenser comprises a metering pump, coupled to thecatheter's proximal end. Such pumps are known in the art, including, forexample, rotating and reciprocating piston metering pumps, peristalticpumps or any other positive displacement pumps capable of dispensingmicro-volumes of liquid with high accuracy. Alternatively, the dispensermay comprise a medical syringe, operated manually by a user of theapparatus.

In other preferred embodiments of the present invention, in particularthose employing controlled-release capsules, the dispenser comprises adiscrete feeder. Preferably, the feeder includes a capsule reservoir, avalve for controlling the passage of capsules, a detector which detectsthe passage of the capsules along the tube, and a controlledphysiological fluid supply to convey the capsules along the tube fromthe reservoir to the distal end of the catheter.

In alternative preferred embodiments, the growth factor administrationis performed by implanting or otherwise securing the catheter or aportion thereof within the myocardium for an extended period. Thedispenser, for example, an osmotic pump, is preferably implanted withina patient's chest and is coupled to the portion of the catheterremaining in the heart, so as to provide treatment over the extendedperiod. Optionally, the dispenser is placed external to the patient'sbody, and the proximal end of the catheter is connected extracorporeallyto the dispenser.

There is therefore provided, in accordance with a preferred embodimentof the present invention, apparatus for intracardiac drugadministration, including a catheter which is inserted into a chamber ofthe heart and brought into engagement with a site in the heart wall, thecatheter including:

at least one position sensor, which generates signals responsive to theposition of the catheter within the heart; and

a drug delivery device, which administers a desired dose of atherapeutic drug at the site determined responsive to the signals fromthe position sensor.

Preferably, the therapeutic drug includes a growth factor. The drug ismost preferably contained in a slow-release matrix, which preferablyincludes a solid capsule.

In a preferred embodiment, the catheter includes a contact sensordisposed on a distal surface of the catheter, which senses contact ofthe surface with the heart wall. Preferably, the contact sensor includesa pressure sensor.

Preferably, the position sensor includes a magnetic position sensor,which generates signals responsive to an externally-applied magneticfield.

Preferably, the position sensor signals are used to generate positionand orientation coordinates, responsive to which the drug dose isdelivered.

In a preferred embodiment, the catheter includes at least onephysiological sensor, which generates signals indicative of theviability of heart tissue at the site. Preferably, the at least onephysiological sensor includes an electrode. Further preferably, theapparatus generates a viability map of the heart based on the signalsand administers the drug responsive thereto.

In another preferred embodiment, the apparatus includes a radiationsource for irradiation of the myocardial tissue, wherein the catheterincludes a waveguide, which communicates with the radiation source.Preferably, the drug delivery device administers the drug into a channelproduced in the tissue by the irradiation, most preferably in the formof a solid capsule.

Preferably, the drug delivery device includes a hollow needle, whichextends distally from the catheter and penetrates the heart tissue todeliver the drug dose.

In a preferred embodiment, the needle has a helical shape and isfastened to the site in the heart wall by a rotational movement of theneedle.

Preferably, the needle is retracted into the catheter before and afterthe drug dose is delivered. Further preferably, the needle extends fromthe catheter through an opening in the catheter, which opening iscovered by a puncture seal. Preferably, the drug delivery deviceincludes a displacement mechanism, which extends and retracts theneedle, wherein the displacement mechanism preferably controls thedistance by which the needle extends from the catheter, so as toadminister the drug at a predetermined depth within the heart wall.

In a preferred embodiment, the drug administration is controlledresponsive to variations in the thickness of the heart wall at the site.Preferably, the catheter includes an ultrasound transducer, whichgenerates signals indicative of the thickness of the heart wall, and thedrug delivery device is gated to administer the drug when the wall at apredetermined thickness.

There is further provided, in accordance with another preferredembodiment of the present invention apparatus for intracardiac therapy,including:

a catheter, which is inserted into a chamber of the heart foradministration of therapeutic treatment to the heart wall;

a sensor, which generates signals responsive to the thickness of theheart wall; and

a controller, which receives the signals from the sensor and controlsthe treatment Responsive to thickness of the heart wall.

Preferably, the sensor includes an ultrasound transducer, which ispreferably fixed to the catheter adjacent to a distal end thereof.

Alternatively or additionally, the sensor includes a position sensor,which is fixed to the catheter adjacent to a distal end thereof.

In a preferred embodiment, the catheter includes a drug delivery device,and the treatment includes administration of a therapeutic substance ata site in the heart wall.

In another preferred embodiment, the apparatus includes a radiationsource, wherein the treatment includes irradiation of the myocardialtissue using the source, and wherein the catheter includes a waveguide,which communicates with the radiation source.

Preferably, the controller gates the treatment so that the treatment isadministered during a portion of the heart cycle. Preferably, thecontroller gates the treatment so that the treatment is administeredwhen the thickness is at a maximum or alternatively, when the thicknessis at a minimum.

There is moreover provided, in accordance with a preferred embodiment ofthe present invention, a method for intracardiac drug administration,including:

introducing a catheter into a chamber of the heart;

sensing position coordinates of the catheter;

positioning the catheter, using the coordinates, in engagement with theheart wall at a desired site; and

administering a therapeutic drug at the site using the catheter.

Preferably, administering the therapeutic drug includes administering agrowth factor. Preferably, the growth factor includes a fibroblastgrowth factor (FGF) or alternatively, a vascular endothelial growthfactor (VEGF). In a preferred embodiment, the growth factor includes agene encoding the growth factor.

Preferably, administering the therapeutic drug includes injecting aslow-release preparation of the drug into the myocardium. Preferably,the slow-release preparation includes a liquid. Alternatively, theslow-release preparation includes a capsule containing the drug which isinserted into the myocardium.

In a preferred embodiment, the method includes irradiating the heartwall, preferably with laser radiation, for engendering revascularizationof the myocardium. Preferably, irradiating the heart wall includesgenerating a channel in the myocardium, and administering thetherapeutic drug includes inserting the drug into the channel.

In another preferred embodiment, positioning the catheter includesverifying contact between the catheter and the heart wall by receivingsignals generated by a contact sensor disposed on the catheter.

Preferably, the method includes receiving physiological signals from theheart, wherein administering the therapeutic drug includes administeringthe drug responsive to the physiological signals. Preferably, thephysiological signals include mechano-physiological signals or,alternatively or additionally, electrophysiological signals.

Preferably, administering the therapeutic drug includes administeringthe drug responsive to a measure of tissue viability determined from thephysiological signals, so that administering the therapeutic drugpreferably includes administering the drug substantially only inischemic but viable areas of the heart. Further preferably,administering the therapeutic drug includes administering the drugresponsive to a map of tissue viability.

Preferably, sensing the position coordinates includes sensingorientation coordinates of the catheter, and positioning the catheterincludes orienting the catheter in a desired orientation relative to theheart wall responsive to the coordinates.

Further preferably, positioning the catheter includes positioning thecatheter relative to a grid of points delineating a zone for drugadministration on a geometrical map of the heart. Preferably sites aremarked on the map at which the drug has been administered.

There is additionally provided, in accordance with a preferredembodiment of the present invention, a method of intracardiac therapy,including:

receiving signals indicative of variations in the thickness of a wall ofthe heart; and

administering a therapeutic treatment to a site in the heart wallresponsive to the thickness variations.

Preferably, administering the treatment includes inserting a catheterinto the heart and bringing the catheter into proximity with the site.

Further preferably, administering the treatment includes irradiating theheart wall with laser radiation conveyed via the catheter.

Additionally or alternatively, administering the treatment includesintroducing a therapeutic drug into the heart wall using the catheter.

Preferably, receiving the signals includes receiving signals from asensor fixed to the catheter, most preferably from a position sensorfixed to the catheter.

In a preferred embodiment, receiving the signals includes receivingultrasound signals.

In another preferred embodiment, receiving the signals includesreceiving electrophysiological signals.

Preferably, administering the treatment includes gating the treatmentresponsive to the thickness variations. Preferably, gating the treatmentincludes administering the treatment when the thickness is substantiallyat a maximum thereof during a cardiac cycle or alternatively, when thethickness is substantially at a maximum thereof during a cardiac cycle.

Additionally or alternatively, gating the treatment includes controllingthe treatment so that the treatment is applied at a desired depth withinthe heart wall.

The present invention will be more fully understood from the followingdetailed description of the preferred embodiments thereof, takentogether with the drawings in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a schematic, partly sectional illustration of a catheterincluding a needle for intracardiac drug delivery, in a first, retractedconfiguration, in accordance with a preferred embodiment of the presentinvention;

FIG. 1B is a schematic, partly sectional illustration showing thecatheter of FIG. 1A in which the needle is in a second, extendedconfiguration;

FIG. 1C is a schematic, partly sectional illustration of a catheterincluding a needle for intracardiac drug delivery, in accordance with analternative preferred embodiment of the present invention;

FIG. 2 is a schematic, pictorial illustration showing a system forintracardiac drug delivery, including the catheter of FIGS. 1A and 1B,in accordance with a preferred embodiment of the present invention;

FIG. 3 is a flowchart illustrating a method of operation of the systemof FIG. 2, in accordance with a preferred embodiment of the presentinvention;

FIG. 4 is a schematic, partly sectional illustration of a catheter foruse in intracardiac drug delivery, in accordance with an alternativepreferred embodiment of the present invention;

FIG. 5 is a schematic, sectional illustration of a human heart, in whichthe catheter of FIG. 4 is inserted for delivery of a drug thereto, inaccordance with a preferred embodiment of the present invention;

FIG. 6A is a schematic, partly sectional illustration of a catheter foruse in performing concurrent laser myocardial revascularization (LMR)and intracardiac drug delivery, in accordance with a preferredembodiment of the present invention;

FIG. 6B is a schematic, pictorial illustration showing a system for LMRand intracardiac drug delivery, including the catheter of FIG. 6A, inaccordance with a preferred embodiment of the present invention; and

FIG. 7 is a timing diagram showing signals associated with LMR treatmentusing the system of FIG. 6B, in accordance with a preferred embodimentof the present invention.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

Reference is now made to FIGS. 1A and 1B, which are schematic, partlysectional illustrations of a catheter 20 for minimally invasiveintracardiac drug delivery, in accordance with a preferred embodiment ofthe present invention. Catheter 20 comprises a hollow needle 24 withinthe catheter's distal end 22, for injection of a drug into themyocardium. In FIG. 1A, the needle is shown in a first configuration, inwhich it is retracted into a sheath 26 inside catheter 20, whereas inFIG. 1B, the needle extends distally out of distal end 22, for injectionof the drug.

Preferably the drug comprises a growth factor, for example VEGF or bFGF,as described hereinabove. In a preferred embodiment, the drug comprisesFGF-4 or FGF-5. In another preferred embodiment, the drug comprises agene therapy agent, such as phVEGF. Needle 24 is connected via a duct 46to a dispenser 54 (FIG. 2) which contains the drug and dispenses it inpredetermined doses through the needle.

Needle 24 preferably has an outer diameter of the order of 1 mm or less.In the extended configuration of FIG. 1B, the needle preferably extends2-3 mm beyond the tip of distal end 22 of catheter 20. Sheath 26 isslightly wider than the outer diameter of the needle and is closed offat its distal end by a suitable seal 28, for example a silicon septum,which precludes back-flow of blood into the sheath and the catheter,while still allowing the needle to be repeatedly extended and retracteddistally from the catheter. As long as needle 24 is retracted, it isfully contained within sheath 26, as shown in FIG. 1A, so that anycontact between the needle and body tissue is substantially precluded.The needle is maintained in this retracted position during insertion ofcatheter 20 into the heart and removal therefrom, as well as while thecatheter is being navigated from point to point within the heart, asdescribed below.

A displacement mechanism 30 drives needle 24 distally out of distal end22 to administer the drug, in the configuration shown in FIG. 1B, andwithdraws the needle back to the position shown in FIG. 1A betweenadministrations. Mechanism 30 preferably comprises a hydraulic pistonwith a suitably constrained stroke length, or an electromechanicaldevice, such as a solenoid, or any other suitable remotely-drivenmechanism known in the art, for example as described in theabove-mentioned U.S. Pat. No. 4,578,061 and incorporated herein byreference. Alternatively, mechanism 30 may comprise a spring-loadedmechanism, which drives needle 24 into the endocardium when triggeredand then pulls the needle back into sheath 26 after drug administration.

A needle sensor 40 is preferably coupled to mechanism 30 and/or needle24 or duct 46. Sensor 40 preferably comprises a pressure transducer orother flow-metering device, as is known in the art, so as to sense anyocclusion of the needle or flow obstruction in the duct, and to ensurethat the proper dosage is delivered through the needle. Additionally oralternatively, sensor 40 comprises a microswitch or other mechanicalsensor, for verifying that needle 24 is fully extended before injectionof the drug and/or fully retracted before the catheter is moved.

Preferably, catheter 20 comprises a tip deflection mechanism 44, forsteering and navigating distal end 22. Preferably, mechanism 44 isoperated by one or more pull-wires (not shown in the figures), asdescribed in the above-mentioned U.S. Provisional Patent Application60/042,872. Alternatively, mechanism 44 may be of any suitable typeknown in the art, such as are described in the above-mentioned PCTPatent Application PCT/US95/01103 or U.S. Pat. Nos. 5,404,297,5,368,592, 5,431,168, 5,383,923, 5,368,564, 4,921,482 and 5,195,968.

Catheter 20 further comprises a position sensor 32, for determination ofposition and orientation coordinates of distal end 22. Preferably,sensor 32 comprises a magnetic position sensor including coils 34, whichgenerate signals responsive to an externally-applied magnetic field, asdescribed in the above-mentioned PCT publication WO96/05768. Thecatheter is navigated and located using the position sensor, so as todeliver the drug, preferably the chosen growth factor, at designated,accurately-chosen sites in the endocardium. Catheter 20 thus allowsprecise, local delivery of the drug, which is required for effectiveadministration of growth factors, in a minimally invasive manner thatcannot be accomplished using apparatus and methods known in the art.

Preferably, catheter 20 also comprises one or more contact sensors 36,for example, pressure sensors, which generate signals responsive tocontact between distal end 22 and the heart wall so to assure propercontact between the catheter and the wall before extension of needle 24.Additionally, the catheter may comprise one or more electrodes 38, whichare used to measure electrical activity in the heart wall, in order toassess and map the local viability of the heart tissue. Methods ofviability mapping are described in greater detail, for example, in PCTPatent Application PCT/IL97/00010, and in U.S. Pat. No. 5,568,809,mentioned above. A viability map may be generated either prior to orconcurrently with the drug administration, as described hereinbelow.

FIG. 1C is a schematic, partly sectional illustration of a catheter 45for intracardiac drug delivery, in accordance with an alternativepreferred embodiment of the present invention. Catheter 45 issubstantially similar to catheter 20, described above, except thatcatheter 45 includes a spiral needle 47. After the catheter is broughtinto engagement with a site in the heart wall where the drug is to bedelivered, needle 47 is screwed into the wall by a corkscrew-likerotational movement. The movement may be achieved either by rotation ofthe needle within the catheter or rotation of the entire catheter.Screwing the needle into the heart wall ensures that catheter 45 willremain firmly in place during the drug administration.

In another preferred embodiment, not shown in the figures, catheter 45has a helical or cylindrical cavity in distal end 22, which enablesneedle 47 to be retracted into the catheter during insertion of thecatheter into the heart and, preferably, during movement of the catheterfrom one drug administration site to another inside the heart.

FIG. 2 is a schematic, pictorial illustration showing a system 48 forintracardiac drug delivery, in accordance with a preferred embodiment ofthe present invention. System 48 comprises a console 50 to whichcatheter 20 is connected at a proximal end thereof. The console includescontrol circuitry 52, preferably comprising a computer, to which a userinput device 56 and a display 58 are preferably coupled, so as to allowa user, generally a physician, to interact with and operate the system.The circuitry is coupled via wires 42 to elements of catheter 20,including sensors 32, 36, 38 and 40, as well as mechanisms 30 and 44, asshown in FIGS. 1A and 1B.

Console 50 also comprises a dispenser 54, which is coupled via duct 46to dispense the drug in predetermined doses through needle 24.Preferably, dispenser 54 comprises a reservoir into which the drug isfilled, in liquid form, and a fluid metering pump communicating with thereservoir. The pump may comprise a rotating or reciprocating pistonmetering pump, a peristaltic pump or any other suitable positivedisplacement pump known in the art, for example, a PiP valveless pistonpump, manufactured by Fluid Metering Inc. of Oyster Bay, N.Y.Alternatively, dispenser 54 may comprise a discrete feeder, forcontrolling the passage of microcapsules from the reservoir through thecatheter, as is likewise known in the art. The microcapsules areimplanted in the myocardium, for example, as shown in FIG. 6A below anddescribed further with reference thereto.

Preferably, circuitry 52 generates a map of the heart, preferably aviability map, which is displayed on display 58. Such a viability map isuseful in identifying suitable candidate areas for drug administration,i.e., ischemic but still viable areas of the heart tissue, to whichgrowth factor therapy could most usefully be applied, as opposed toinfarcted and non-viable areas or to well-perfused and healthy areas,for which growth factor therapy would either be unuseful or toxic.Circuitry 52 determines and marks a grid of points on the map, coveringa candidate area at a desired density (point-to-point spacing), at whichthe drug is to be administered. The viability map may be generated in aseparate procedure, before insertion of catheter 20 for administrationof the drug, but is preferably generated concurrently with orimmediately prior to drug administration, making use of position sensor32 and electrode 38 to map the heart's electrical activity.

FIG. 3 is a flow chart showing a method for concurrent viability mappingand drug administration, using system 48 and catheter 20, in accordancewith a preferred embodiment of the present invention. The catheter isinserted into the heart, preferably percutaneously, and is navigated,either automatically or under user control, to a candidate area for drugadministration. Using position sensor 32, distal end 22 is positionedagainst the endocardium, generally perpendicular to the surface thereof,at a candidate location for drug administration. Preferably, circuitry52 receives and analyzes signals from contact sensors 36 to ensurepositive contact between the catheter's distal end and the endocardium.Alternatively or additionally, circuitry 52 may receive readings fromthe position sensor over several cardiac cycles, and to the extent thatthe position coordinates thus determined remain substantially constant(for any given phase of the cardiac cycle), it is assumed that distalend 22 is in positive contact with the endocardium.

Once distal end 22 is securely positioned, circuitry 52 assesses theviability of the heart tissue at the location of the distal end,preferably based on the waveform and amplitude of electrogram signalsreceived by electrodes 38. A motion profile of the heart wall at thelocation may also be generated, by taking position readings from sensor32 at multiple phases of the heart cycle and may be used, as well, inthe viability assessment. In this manner, circuitry 52 preferablyverifies that the heart tissue in a vicinity of the location of distalend 22 is ischemic but still viable before administering the drug at thelocation. As noted hereinabove, administration of drugs, such as growthfactors, to non-ischemic areas of the heart can have deleteriouseffects, and generally speaking, it is desirable to apply no more thanthe precise dosage required in order to avoid possible systemictoxicity. For these reasons, circuitry 52 preferably preventsadministration of the drug at locations that do not meet the criteria ofviability described above, or at least notifies the user of theviability status of such locations.

Once it has been ascertained that distal end 22 of catheter 20 is firmlypositioned at an ischemic site, needle 24 is extended out of sheath 26,as shown in FIG. 1B, and a dose of the drug is administered. Circuitry52 marks the location, viability status and dosage information on themap of the heart, and the catheter is moved on to the next point on thegrid. The procedure preferably continues until the entire candidate areahas been covered, whereupon the catheter is withdrawn from the heart.The viability mapping procedure may be repeated at a later date in orderto assess the effectiveness of the drug treatment and, if necessary,administer additional dosage thereof.

Catheter 20 may, additionally or alternatively, include other types ofsensors, for use in controlling and/or monitoring the drugadministration and in viability mapping of the heart. Mapping cathetershaving sensors of various types described, for example, in theabove-mentioned PCT Patent Application PCT/IL97/00010 and U.S. Pat. No.5,568,809. Other physiological detectors may be employed, as well, forexample, perfusion detectors, which measure local microcirculation bloodflow rates, or optical detectors, which sense fluorescent emissionrelated to local blood perfusion.

FIG. 4 is a schematic, partly sectional illustration of another catheter64 for intracardiac drug injection, in accordance with a preferredembodiment of the present invention. Catheter 64 is generally similar tocatheter 20, described above, but also includes an ultrasound transducer60, which emits a beam of ultrasonic radiation 62 and receivesultrasound waves reflected from the heart wall. Transducer 60 ispreferably used to measure and map the thickness of the heart wall, asdescribed in the above-mentioned PCT patent application PCT/US95/01103.Alternatively or additionally, the transducer may be used to produce anultrasound image of the endocardial and/or endocardial surface. In thiscase, the transducer preferably comprises an array of transducerelements, so that a detailed image can be produced with high resolution.

FIG. 5 is a schematic, sectional illustration of a heart 70 into whichcatheter 64 is inserted, for administering a drug thereto. As describedabove, distal end 22 of catheter 64 is brought into engagement withendocardium 72. Ultrasound signals received by transducer 60 are used tomeasure the distance from the endocardium to the outer surface ofepicardium 74, so that the thickness W of the heart wall is determined.Assuming that distal end 22 is properly positioned at a suitable, viablelocation for drug administration, needle 24 is extended out of thecatheter into myocardium 76.

Preferably, dispensing of the drug through needle 24 is gated responsiveto changes in the thickness of the wall. It is believed that optimaldispersion and retention of the drug within myocardium 76 is generallyachieved when the needle dispenses the drug roughly midway through themyocardium. The thickness of the heart wall varies, however, as theheart contracts and expands, and this variation may be measured usingtransducer 60. Since the length of the needle is known, the drug ispreferably dispensed when the thickness W of the wall is approximatelyequal to at least twice the length of the needle extending out of thecatheter, as shown in FIG. 5. Alternatively, dispensing of the drug maybe gated at any desired wall thickness, and the drug may be dispensed atsubstantially any desired depth within the heart wall. Furtheralternatively or additionally, the depth of insertion of needle 24 maybe controlled responsive to the thickness W, so that the greater thethickness, the deeper is the needle inserted.

FIG. 6A schematically illustrates distal end 22 of a catheter 78 forcombined performance of laser myocardial revascularization (LMR) andintracardiac drug administration, in accordance with another preferredembodiment of the present invention. FIG. 6B is a schematic, pictorialillustration of a system 96 for combined LMR and drug therapy, usingcatheter 78. System 96 comprises control console 50, substantially asdescribed above with reference to FIG. 2, except that in system 96 theconsole also includes a laser source 94 for use in the LMR procedure.

In the embodiment of FIGS. 6A and 6B, the drug to be administered,preferably comprising a growth factor, is preferably incorporated withina solid polymeric matrix capsule 88. The capsule is passed fromdispenser 54 within a suitably pressurized carrier fluid through achannel 92 running along the catheter and is inserted using the catheterinto the heart wall. A one-way valve 90 preferably closes off the distalend of channel 92, allowing capsule 88 to exit therefrom, but preventingblood or debris from entering and possibly clogging the channel.

Catheter 78 also comprises a waveguide 80 connected proximally to lasersource 94 and distally to optics 82, which focus radiation from thelaser source into the heart wall. Catheter 78 preferably comprisesposition sensor 32 and one or more contact sensors 36 and/or electrodes38, as well as a steering mechanism (not shown in FIG. 6A), as describedabove. Catheter 78 is preferably fed percutaneously through a bloodvessel, such as the aorta, into a chamber of the heart and navigated toan ischemic area of the heart using the steering mechanism and theposition sensor.

At each point on a grid in the ischemic area, as determined anddesignated on a map of the heart by control circuitry 52, laser source94 is activated to generate a revascularizing channel within themyocardium, as described, for example, in the above-mentionedPCT/IL97/00011 patent application. Upon generation of the channel, aslow-release capsule 88, designed to fit within the LMR channel, isejected from duct 92, which is provided with a suitably curved distalportion, through valve 90. Alternatively, the drug may be dispensedusing any other suitable type of solid capsule delivery system known inthe art, for example, as described in U.S. Pat. Nos. 4,588,395 and4,578,061, mentioned above.

Preferably, capsule 88 is designed so that its dimensions remainsubstantially constant throughout the treatment period, so as to securethe capsule in place at the designated location and preclude accidentaldrift, thus assuring appropriate localized administration of the drugthroughout the treatment duration. Further preferably, the medium inwhich the growth factor is embedded comprises a biocompatible polymericmatrix along with other auxiliary agents, for example heparin, asdescribed in the above-mentioned articles by Harada et al and by Isner.The growth factor is leached out of the capsule by myocardial bloodcirculation, due to an osmotic gradient between the capsule and thesurrounding tissue, and is dispersed within the tissue. Preferably, thecapsule is designed to disintegrate upon completion of the treatment, byemploying a suitable mechanism. For example, the matrix solubility maybe coordinated with the drug diffusion rate, or a fast matrix solubilitymay be triggered in response to a certain concentration level of apredetermined component. Thus, upon reaching the treatment's end-point,the capsule is rapidly dissolved and its components washed away.

Although catheter 78 is described hereinabove as delivering solid drugcapsules concomitantly with LMR irradiation, it will be understood thateach of these elements can be used independently of the other in drugadministration protocols. For example, capsule 88 may be implanted inthe heart wall using a needle (like needle 24, suitably adapted) orother microsurgical implement, or by means of a burst of pressurethrough duct 92.

Further alternatively, the LMR therapy may be performed in conjunctionwith administration of a drug, such as a growth factor, in a liquidmatrix. In this case, a needle, such as needle 24, punctures the heartwall and administers the drug at a site in the vicinity of the LMRchannel, such that the channel's borders are within a radius ofinfluence of the growth factor during at least a major portion of thedrug's therapeutic life. The use of the growth factor and LMR togetheris believed to further facilitate angiogenesis, as mentioned above.

FIG. 7 is a timing diagram, which schematically illustrates signals usedin controlling laser source 94, in accordance with a preferredembodiment of the present invention. The laser source is triggeredresponsive to an ECG signal, received either from body surfaceelectrodes on the skin of a patient undergoing the therapy, or fromelectrode 38 on catheter 78. Triggering the laser in this manner ensuresthat the laser pulse will be fired into the myocardium when the heartwall is at a certain, desired thickness, preferably at its greatestthickness, during systole.

As shown in FIG. 7, after catheter 78 is suitably positioned against theendocardium, the ECG R-wave peak is detected, and a position reading istaken from position sensor 32 within a short time, preferably 20-50 msecthereafter. The R-wave is detected and position readings are taken forseveral heart cycles in succession. Circuitry 52 tests the R-R intervalsof successive cycles, and also compares the successive positionreadings. The purpose of this comparison is to ensure that both thepatient's heart rhythm and the positioning of distal end 22 are stablebefore firing the laser. Therefore, circuitry 52 enables laser source 94only if the R-R interval is within a predetermined limit of the intervalin two or more preceding cycles, preferably within ±12% or 120 msec, andif the position reading from sensor 32 has not shifted by more than apredetermined distance, preferably in the range of 0-12 mm, mostpreferably in the range of 3-6 mm.

After circuitry 52 has verified the stable heart rhythm and catheterposition, it provides a laser enable pulse once every heart cycle, at apredetermined delay following the detection of the R-wave in each cycle.The delay is adjusted, either automatically by circuitry 52 or by theuser of system 96, so that the laser will fire only at a point in theheart cycle at which the heart wall has a desired thickness. When theuser activates a laser switch on console 50, the laser fires a train ofone or more radiation pulses in response to each laser enable pulseprovided by circuitry 52. Due to delays inherent in high-voltageelectronics used to drive laser source 94, the laser pulse train willgenerally be delayed relative to the rising edge of the laser enablepulse by an insignificant, random delay, generally about 5-25 msec.

Optionally, an ultrasound transducer, such as transducer 60 shown inFIG. 4, is used to measure the thickness, so as to trigger laser source94 accordingly. Alternatively or additionally, variations in theposition readings received from sensor 32 in the course of a heart cyclemay be used to estimate the heart wall thickness and/or trigger thelaser. In any case, the laser is preferably controlled to fire when theheart wall is at its thickest, so as to create a relatively wide channelin the myocardium while reducing the risk that the channel willpenetrate through the epicardium.

Angiogenesis Through Cell Delivery

For purposes of the present invention, the term therapeutic drug alsoincludes a cell utilized for angiogenesis. As it has been established inthe art, cells such as myoblasts or myocytes, and more specificallycardiomyocytes, are utilized to transfer a recombinant molecule such asa gene or their promoters in order to treat various forms of disease.The use of cells as a delivery vehicle, such as an expression vector,for delivering therapeutic substances is described in U.S. Pat. No.5,602,301 (Field, Loren) and WO 96/18303 (Law, Peter) which areincorporated by reference herein. In this respect, the myoblasts ormyocytes are utilized as a universal gene transfer vehicle and aredelivered directly to tissue such as cardiac tissue. Accordingly, themyoblasts or myocytes are used as expression vectors for ultimatelyexpressing therapeutic substances such as recombinant proteins and othermolecules which provide a therapeutic effect on the tissue. Forinstance, one such therapeutic effect is utilizing the myoblasts ormyocytes as delivery vehicles responsible for expressing an angiogenicfactor such as a growth factor or other protein. These growth factors,in turn, are responsible for establishing collateral vessels and providefor angiogenesis of the tissue. These collateral vessels are formed byangiogenic factors such as basic and acidic fibroblast growth factor(FGF), transforming growth factor (TGF), vascular endothelial growthfactor (VEGF) or the like. This type of therapeutic approach is clearlyadvantageous for those tissues or organs that require enhanced bloodflow. For instance, this application is particularly useful inrevascularizing the cardiac tissue of the heart.

One advantage of using a cell delivery approach is that it eliminatesthe use of a viral vector since there is sometimes a bias against usinga virus as a delivery vehicle. Instead of using a virus as a deliveryvehicle, the present invention utilizes cells that have beenspecifically engineered for expressing the desired growth factor, suchas those mentioned above, or other factors or proteins.

Another advantage of a cell delivery approach is that the rates oftransfection that can be achieved ex-vivo are much higher than therather low rates of transfection reached in-vivo when viral vectors areutilized. The cell delivery approach is a dramatic improvement over aviral vector approach since it clearly increases the efficiency of thetherapeutic treatment significantly.

Additionally, another advantage of utilizing transplanted cells as adelivery vehicle is that these cells are less likely to migrate from theinjection site as is sometimes found with viral vectors or growthfactors. Thus, the cell delivery therapy is truly a localized approachand provides focused treatment to the heart tissue.

Yet, another advantage of a cell delivery approach is that theexpression of growth factors by the delivered cells can last as long asthe cell's lifetime, e.g. for as long as the cell survives, oralternatively, for as long as the program of the engineered cell, e.g.for as long as the cell is smartly programmed for expression to beactivated or deactivated. This latter approach is truly a “controlledrelease” for the expressed growth factor of the delivered cell. Thisprovides a distinct advantage over a vector or growth factor deliveryapproach because these approaches are naturally limited in time.

Myogenesis Through Cell Transplantation

For purposes of the present invention, the term therapeutic drug alsoincludes any type of cell capable of being transplanted for myogenesispurposes. It is known that cells such as myoblasts or myocytes can beused for promoting myogenesis through transplantation of the cells. Thisparticular technology is described in WO 96/18303 (Law, Peter) and U.S.Pat. No. 5,602,301 (Field, Loren) which are incorporated by referenceherein. In order for myogenesis through cell transplantation to besuccessful, it is important to identify and utilize those cells that arecapable of fusion with other cells.

One technique is to utilize donor myoblasts which can be obtained frompublic depositories. In general, myoblasts have characteristics such aspermitting fusion amongst each other which allows for the formation ofgenetically normal myofibers. This process allows for the replenishmentof degenerated myofibers and permits full compliments of normal genes ofthese myoblasts to be integrated into abnormal cells of an organtargeted for this type of therapy. It is also contemplated that cellssuch as stem cells can be cultured and treated in order to obtain adesired cell suitable for transplantation into an organ or muscle suchas the heart.

When utilizing donor myoblasts, these cells are sometimes treated. Onesuch treatment is the use of immunosuppressants. While another treatmentof these myoblasts, is directed toward making a genetically superiorcell line.

Another source of cells, such as myoblasts, that are capable of beingutilized for myogenesis is a source of myoblasts derived from thepatient. This is a biopsy and seeding technique as described in WO96/18303 (Law, Peter) at page 9. The first step in this technique is toobtain a muscle biopsy from the patient from either cells harvestedsometime prior to an injection procedure or immediately along with theinjection procedure, e.g. in conjunction with an injection procedure.The next step is to transfect a “seed” amount of satellite cells with anormal gene. Myogenicity of the transfected cells is then confirmed.Next, transfected myoblasts are proliferated enough to produce abeneficial effect when transplanted. The last step is then to administerthe myoblasts into the patient at the targeted site through a deliverysystem.

Another biopsy technique is to harvest cardiomyocytes directly from thepatient and treat in a manner that permits a sufficient number ofcardiomyocytes to be proliferated for administering back into thepatient at sites requiring normal cells. The object is to target thoseregions in the cardiac tissue that are viable and biopsy at those sitesonly, such that the harvested cardiomyocytes, after treatment, can betransplanted at regions requiring therapy such as myocardial infarctregions, scar tissue regions, ischemic zones or any other area in theheart deemed appropriate for transplanting treatment.

Another technique for transplanting cells is to utilize xenografts,e.g., those cells derived from a non-human source such as a mammalianmodel. These cells or xenografts can be treated in a manner such as thatdescribed above, e.g. through the use of immunosuppressants, andtransplanted at those regions of the organ, particularly the heart,where abnormal cells currently exist.

Method of Delivery

In order for a successful deployment of the cell therapy techniquesdescribed above, the drug delivery system 48 (FIG. 2) and the LMR anddrug delivery system 96 (FIG. 6B) are particularly useful for thispurpose. By way of example, the cells are delivered through the catheter20 (FIG. 1A and FIG. 1B), catheter 45 (FIG. 1C) and catheter 64 (FIG.4). As described previously, a viability map is created using the system48 or the system 96 respectively in order to create a viability map. Aviability map of the heart is generated by circuitry 52 and displayed ondisplay 58. One useful purpose of the displayed viability map is toidentify ischemic zones in the cardiac tissue, e.g. those regions of thecardiac tissue that are still viable and require therapy. Additionally,the viability map is also useful for identifying regions effected bymyocardial infarct and scar tissue as well as anatomical landmarkswithin the heart. The system 48 and 96 respectfully permit for theexpedient composition of a targeted therapy plan by utilizing circuitry52 for determining and marking a grid of points on the viability map aspart of the target plan. Thus, the physician plans the desired densityof the cell delivery through point-to-point spacing.

It is important to note that the physician is not limited to utilizing aviability map created by the system 48 or the system 96 as describedabove. But rather, the physician may utilize other types of viabilitymaps created through other mapping techniques prior to the celltherapeutic procedure.

Utilizing the system 48 or the system 96, the physician has the abilityto develop a therapy delivery plan as desired. The therapy delivery plancan consist of targeting only those regions of the heart effected bymyocardial infarct or scarring or the plan may target other regions ofthe heart such as the ischemic zones. When targeting infarct regions,the physician will mark the infarct zones on the viability map as wellas determine an infarct to normal tissue ratio. As part of the celldelivery plan, preferred injection sites at or within the infarct regionare identified and marked on the viability map. Preferred injectionsites may actually reside on the border of an infarct scar.

Once the injection sites have been identified, the catheter 20, 22 or 45is positioned at each target site and the therapeutic cells aredelivered at each site according to the therapy delivery plan. Onetechnique for obtaining maximum benefit and takeup of the deliveredcells, is to deliver or inject the cells at an oblique angle at thesite. The catheter can be positioned at the appropriate oblique angleusing the position information obtained using the position sensor (32)that is located at the tip of the catheter.

As mentioned above, the cells delivered at each site can be either amyoblast or myocyte, such as a cardiomyocyte. Both cell deliveryapproaches are acceptable for use with the present invention.Accordingly, either the cells can be delivered as an expression vectorcapable of expressing an angiogenic factor or a cell fusion mechanismcapable of resulting in myogenesis.

The cells may be either injected through a delivery device such as ahollow needle 24 or a spiral needle 47 as particular examples.Additionally, another delivery technique suitable for the presentinvention, is to create channels prior to delivery of the cells. Thesechannels can also be created at an oblique angle at the target site andare achieved through a suitable channel creating technology. Onepreferred embodiment for creating these channels is to utilize an LMRand drug delivery catheter 78 (FIG. 6A) in order to first create a laserchannel with optics 82, and then to deliver the cells directly into thecreated channel.

It is important to note that the specific delivery devices mentionedabove are just some of the delivery mechanisms contemplated by thepresent invention. Alternative delivery devices such as pressure burstsare also contemplated by the present invention. Additionally, asmentioned previously, the needle 24 and needle 47 are retractable intoand out of the distal end 22 of the catheter 20 and the catheter 45respectively. The retraction can be either manually controlled orcomprise an automatic retraction through the use of the displacementmechanism 30 (FIG. 1A and FIG. 1B) such as a spring loaded mechanismwhich automatically retracts the needle 24 after delivery of the cells.

Once the targeted delivery plan has been executed, viability maps can betaken of the cardiac tissue over time in order to track changes of hearttissue characteristics and confirm the viability of the tissue aftertherapy.

Another method according to the present invention is to harvestcardiomyocytes through biopsy of the myocardium. This is done byinserting a biopsy catheter into the heart chamber and performing abiopsy, usually from the septal wall. The most common complication ofmyocardium biopsy is perforation of the heart wall. In patients withheart disease that are the candidates for the proposed treatment, thereis a possibility that one or more of the infracted or ischemic zones arein the septal wall. It would thus be advantageous to perform the biopsyfrom the most healthy part of the myocardium. This is accomplished byusing the viability map to determine the best site for the biopsythrough identification of ischemic regions and healthy tissue regionsand then using a biopsy catheter with a location sensor to navigate tothat site and perform the biopsy in the healthy tissue region in thesafest way possible. These biopsy or harvested cells are then treatedand transplanted according to the techniques described above.

It will be appreciated that the preferred embodiments described aboveare cited by way of example, and the full scope of the invention islimited only by the claims.

1. A method for inducing angiogenesis or myogenesis in a heart of apatient comprising the steps of: providing a system for intracardiacdrug administration comprising a catheter, said catheter having at leastone position sensor which generates signals responsive to an appliedfield for determining the position and orientation of said catheter,said signals being used to generate position and orientationcoordinates, and a drug delivery device for delivering said cell, thesystem also comprising control circuitry for determining position andorientation coordinates of a distal end of said catheter and forgenerating a viability map of said heart comprising a site suitable fortargeted therapy by said catheter; generating the viability map of theheart; identifying said site suitable for targeted therapy on saidviability map; inserting said catheter into a chamber of said heart atsaid site; delivering said cell to said site with said drug deliverydevice based on position and orientation coordinates in response to saidsignals from said position sensor, and inducing angiogenesis ormyogenesis in said site of said heart from said delivered cell.
 2. Themethod according to claim 1, wherein said cell is a myoblast or amyocyte.
 3. The method according to claim 2, including assessing theviability of said heart prior to delivering said cell.
 4. The methodaccording to claim 3, including delivering said cell based on theassessed viability of said heart.
 5. The method according to claim 4,including assessing the viability of said heart with said viability mapof said heart.
 6. The method according to claim 5, including identifyingan ischemic zone of said heart on said map as the site suitable fortargeted therapy.
 7. The method according to claim 6, includingdetermining a delivery site within said ischemic zone.
 8. The methodaccording to claim 7, including assessing the viability of said heartafter delivering said cell.
 9. The method according to claim 5,including identifying an infarct region of said heart on said map as thesite suitable for targeted therapy.
 10. The method according to claim 9,including determining a delivery site at said infarct region.
 11. Themethod according to claim 10, including assessing the viability of saidheart after delivering said cell.
 12. The method according to claim 2,wherein said cell is an expression vector capable of expressing anangiogenic factor.
 13. The method according to claim 12, wherein saidexpression vector includes a recombinant molecule.
 14. The methodaccording to claim 13, wherein said recombinant molecule is a gene. 15.The method according to claim 12, wherein said angiogenic factor is agrowth factor.
 16. The method according to claim 2, wherein said cell iscapable of cell fusion with other cells.
 17. The method according toclaim 16, wherein said cell fusion results in myogenesis.
 18. The methodaccording to claim 17, wherein said cell is derived from a donor. 19.The method according to claim 18, wherein said cell is treated prior todelivery.
 20. The method according to claim 19, wherein said cell istreated with an immunosuppressant.
 21. The method according to claim 17,wherein said cell is harvested from said patient.
 22. The methodaccording to claim 21, wherein said cell is treated prior to delivery.23. The method according to claim 22, wherein said treatment results ina genetically superior cell.
 24. The method according to claim 22,wherein said cell is a xenograft.
 25. The method according to claim 1,including creating a channel at said site prior to delivering said cell.26. The method according to claim 25, including creating said channelwith a laser.
 27. The method according to claim 12, including creating achannel at said site prior to delivering said cell.
 28. The methodaccording to claim 27, including creating said channel with a laser. 29.The method according to claim 16, including creating a channel at saidsite prior to delivering said cell.
 30. The method according to claim29, including creating said channel with a laser.
 31. The methodaccording to claim 1, including delivering said cell at said site at anoblique angle.
 32. The method according to claim 31, wherein said drugdelivery device includes a needle.
 33. The method according to claim 31,wherein said drug delivery device is capable of providing a pressureburst.
 34. The method according to claim 32, wherein said needle isretractable.
 35. The method according to claim 25, wherein said drugdelivery device includes a needle.
 36. The method according to claim 25,where said drug delivery device is capable of providing a pressureburst.
 37. The method according to claim 35, wherein said needle isretractable.
 38. The method according to claim 27, wherein said drugdelivery device includes a needle.
 39. The method according to claim 27,wherein said drug delivery device is capable of providing a pressureburst.
 40. The method according to claim 38, wherein said needle isretractable.